SG16 - Sex, sexuality, gender diversity and health contextual unit

Rationale

Diverse sex, sexuality and gender create a complex tapestry in Australian general practice. For some individuals, gender identity and sexual orientation are fixed and clear, while for others, identity and orientation may be more fluid. It is therefore imperative for general practitioners (GPs) to have a good understanding of the diversity of sex, sexuality and gender in Australia, and to approach every individual in a holistic and non-judgemental way, minimise discrimination and obstacles to care access, and optimise the quality of healthcare that they provide.

The title of this contextual unit is intentionally broad to encompass individuals who may identify as lesbian, gay, bisexual, transgender, intersex, queer (LGBTIQ), asexual, pansexual, those who do not identify with any particular gender or sexual orientation, and those who prefer not to be categorised. The purpose of this unit is to challenge the ‘binary’ approach to provision of healthcare by GPs, in which assumptions and judgements are made about anindividual’s sex, sexuality and/or gender based on appearances and/or what is considered by the individual GP to be ‘normal’. This approach is essentially flawed and typically impacts the quality of care that can be provided.

It is estimated that up to 8% of Australians are gender diverse,1 and individuals who are intersex constitute approximately 1.7% of births in Australia.2A recent population-based sample of over 20,000 people aged 16–69 found that 14.7% of women are same-sex attracted, 13.5% engage in same-sex behaviour, 1.2% are lesbian and 2.2% bisexual; and 6.8% of men are same-sex attracted, 6.0% engage in same-sex behaviour, 1.6% are gay and 0.9% bisexual.3

In the 2011 Census of Population and Housing, same-sex couples represented 1% of all couples in Australia and 0.1% of children were a part of a same-sex couple family unit.4Children of same-sex couples had significantly better academic scores when compared to all other children from other family contexts; notably, there were no differences in health measures assessed.5 The number of same-sex couples reported on census data tripled between the years 1996 and 2011. People in same-sex relationships tend to be more highly educated (with 42% having a bachelor degree or higher qualification, compared with 23% of non–same-sex couples) and have higher workforce participation rates (89%, compared with 67%).4

It is important to note that groups of sex, sexuality and gender diverse individuals are not mutually exclusive and also are not homogenous. Transgender and gender diverse people can have any sexual orientation, and lesbian, gay, bisexual or intersex people may have fluid or transgender identities. Within this diversity, many have a shared experience of being a minority population, likely to have been discriminated against and exposed to stigma throughout their lives.2 It is important for GPs to acknowledge these vulnerabilities and recognise where there is diversity within diversity. Examples of these groups may include Aboriginal and Torres Strait Islander peoples, those living in rural and remote areas, and refugees and asylum seekers. It is important to note that older people who identify as lesbian, gay, bisexual, transgender or intersex (LGBTI ) may have lived through a time where sexual orientation and diverse gender identity were considered to be mental illnesses or criminal offences (particularly for gay men), thus they may have learned to hide their sexual and/or gender identity.

Intersex individuals are noted to be a particularly vulnerable group. They are born with physical, hormonal or genetic features that are neither wholly female or wholly male, a combination of female and male, or neither female nor male.6Like the rest of the Australian population, they have a broad range of gender identities and sexual orientations. Many individuals in this group have undergone surgical and/or hormonal treatments at a young age that have caused them to appear as either male or female. Evidence suggests that a significant proportion of individuals who are intersex are resentful of the interventions they received and consequently avoid accessing healthcare, thus putting them at increased risk.7

Health disparities unfortunately exist in Australia. Individuals who identify as LGBTI tend to be disadvantaged, and this is thought to be linked partly to societal stigma and partly to barriers to health service access. In recent times, legislative reforms have created a social environment that generally promotes equality. A notable example of this was the 2013 amendment to the Sex Discrimination Act 1984 (Cwlth) that made discrimination based on sexual orientation, gender identity or intersex status illegal.8Despite these legislative changes, people who identify as LGBTI continue to experience significant inequalities in society and in health outcomes, which appear to be partly due to difficulties accessing culturally sensitive care. Conversely, access to sensitive primary care can increase disclosure of diverse sexual orientation, gender identity and intersex status. This, in turn, can increase tailored health promotion opportunities and improve access to counselling, drug and alcohol services, and to LGBTI-specific resources.9

Significant proportions of LGBTI people report hiding their sexuality or gender identity at work (39%), at social and community events (42%) and when accessing services (34%).10 Verbal homophobic abuse has been experienced by 60% of LGBTI individuals, and 20% have experienced physical abuse. It is important to recognise that young people are particularly at risk of bullying based on their sexual or gender identity. Eighty per cent of homophobic bullying involving LGBTI individuals occurs at school and can have a devastating impact on wellbeing and education.10

The mental health status of sex, sexuality and gender diverse people in Australia is of significant concern. Individuals who identify as lesbian, gay and/or bisexual (LGB) are approximately three times more likely than heterosexual people to experience depression.11 Transgender male and females are at the highest risk for both abuse and depression,9 and 20% of individuals who identify as transgender and 15.7% of individuals who identify as LGB report regular suicidal ideation.9,12

Discrimination against sex, sexuality and gender diverse people has been directly linked with substance abuse, mental health disorders and suicide.11Discrimination is experienced in a variety of forms including rejection by families of origin, abuse from peers and strangers, marginalisation from social groups and within work and educational settings, and exclusion from social and legal institutions. It is well recognised that the more discrimination faced, the poorer an individual’s health and wellbeing.13,14

A 2009 systematic review15 found that the experiences of individuals identifying as LGB with healthcare were ‘generally poor’. The major obstacles to quality care, as identified in this review, included assumptions of heterosexuality, communication barriers due to health professional discomfort, poor knowledge of the health professional about LGB issues, and lack of LGB resources and referral networks.

GPs have an important role to play in advocating to reduce discrimination and in creating meaningful therapeutic relationships with LGBTIQ individuals to improve healthcare access. The establishment of high-quality therapeutic relationships and delivery of quality care to these individuals draws on the core skills in The Royal Australian College of General Practitioners’ (RACGP’s) 2016 curriculum (CS16), in particular:16,17

recognising the GP’s own cultural lens and biases, as these can be very damaging to a therapeutic relationship and negatively impact future possibility of disclosure and continuity of care

appropriate, sensitive enquiry about sexual orientation

avoiding the assumption of heterosexuality

understanding that sexuality can be fluid and that identity, attraction and behaviour are not necessarily congruent

realising a need for open-mindedness and avoidance of assumptions; in particular, avoiding ‘heteronormative’ language on patient intake forms and including options for the spectrum of gender and sexual diversity and when meeting new patients

acknowledging the role of the same-sex partner and/or chosen family in the individual’s life

providing ongoing support through high-quality continuity of care to enhance health service access for people who identify as LGBTI

providing non-judgemental holistic care that is affirming and positive when disclosure occurs and based on sound knowledge of any mental or physical health risks and requirements for screening, because like many others in the Australian population, many sex, sexuality and gender diverse individuals do not want to be solely defined by their gender or sexual identity

knowledge about the issues faced by transgender individuals, including recognition of gender dysphoria, medical and surgical options available for those wishing to affirm their gender, and an understanding of referral options available

familiarisation of LGBTI-sensitive referral networks and resources, to which individuals can be linked in if they choose

teaching about provision of quality care to LGBTI individuals to encourage culturally competent care to colleagues and challenging discriminatory views – this being an important part of GP advocacy.

Useful resources for LGBTIQ people

QLife, counselling and referral service for people of diverse sex, genders and sexualities, providing nationwide early intervention, peer-supported telephone and web-based services for LGBTIQ people of all ages, including a national resources list

Crouch S. The Australian study of child health in same-sex families (ACHESS): Interim report. Carlton, Vic: Melbourne School of Population Health, University of Melbourne, 2014. [Accessed 4 April 2016].

Couch M. Tranznation: A report on the health and wellbeing of transgender people in Australia and New Zealand. Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University, 2007.